ICD-10 code for pleural effusion: While assigning, sometimes coders find it challenging to assign. Today, we are discussing the correct ICD-10 codes for pleural effusion, including right, left, and malignant.
What is a pleural effusion?
A pleural effusion means an excessive amount of fluid present in the pleural membrane between the pleura and the chest wall. Heart failure, infection, cancer, pneumonia, liver disease, and other illnesses are some of the causes.
Common ICD-10 Code for Pleural Effusion
• J90 – Pleural effusion, not elsewhere classified
• J91 – Pleural effusion in conditions classified elsewhere
• J91.0 – Malignant pleural effusion
• J91.8 – Pleural effusion in other conditions classified elsewhere
Synonyms
- Bacterial pleurisy with effusion
- Bilateral pleural effusion
- Exudative pleural effusion
- Loculated pleural effusion
- Pleural effusion
- Pleural effusion bacterial, nontuberculosis
- Pleural effusion due to bacterial infection
- Pneumococcal pleurisy with effusion
- Strep pleurisy with effusion
- Streptococcal pleurisy with effusion
Pneumonia with Pleural Effusion
Pleural effusion, while seen in cases of pneumonia, is not inherent or that common. If physicians note pleural effusion and the patient does not have a history of CHF, we should report it. This shows a higher level of severity of illness. If they document it as “due to,” “with,” or similar terminology to show association with pneumonia, we report it with the code J91.8
FAQ:
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CXR imaging was interpreted independently by me and my attending physician and showed persistent right-sided pleural effusion and nonspecific right basilar airspace disease appearing similar to the previous study. New small bilateral pleural effusion. Moderate cardiomegaly and pulmonary vascular congestion.
ANS: Bilateral pleural effusion ICD-10 J90 Pleural effusion, not elsewhere classified
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The final impression is pleural effusion, not elsewhere classified, and shortness of breath and chest pain. How will we code this scenario?
ANS: The chest pain and SOB are the symptoms of pleural effusion, so we will code only pleural effusion
Read more: How To Code ICD-10 For COPD And Related Conditions and Its Physiology
Reference: AAPC
